Sunday, February 28, 2010

WebMD's Big Lie

In order to provide quality web-based health content, you need money. The question is how you choose to make that money. WebMD, like many web sites, makes money from advertising, but it consistently goes several steps further, allowing its content to be transformed into one long stream of stealth advertising.

The incredibly successful company was just caught red-handed by Senator Chuck Grassley, who saw a WebMD television commercial encouraging viewers to log on to the site in order to take a depression screening test. When Grassley navigated over to the test, he found that it was funded by Eli Lilly—information that was apparently omitted from the TV commercial.

What's the big deal? At first blush, this looks like business as usual. I read through the test, which appears to simply go through the DSM-4 criteria for depression, one at a time. Nor is the test actually written by Lilly. In fact, at the top of the page is the statement “This content is selected and controlled by WebMD's editorial staff and is funded by Lilly USA.” So it would appear that Lilly paid WebMD staff to encourage people to discover whether they have depression, and to seek appropriate treatment from their doctors. Yes, some of these patients might end up on Lilly’s antidepressant Cymbalta, but others would be prescribed competing antidepressants. Looked at this way, this isn’t particularly deceptive or nefarious. In fact, it might be interpreted as a public health service--enhance awareness of depression, and everybody benefits.

Now, nobody would insist that the nine DSM criteria are the be-all and end-all of depression. Depressed patients often experience problems that are not specifically included in DSM-4’s list. These include symptoms and behaviors like lowered sex drive, irritable mood, excessive use of drugs or alcohol, and, yes, various physical aches and pains. There are many more. So why, out of the dozens of possible depressive symptoms not listed in DSM-4, did WebMD decide to ask about one, and only one, in particular: aches and pains?

Because Lilly markets Cymbalta as the "go to" antidepressant for patients who have both depression and physical pain. This is not really a "depression screening test" at all. Instead, it is a "Cymbalta-requester" screening test.

WebMD is telling the public a big lie. The say that “this content is selected and controlled by WebMD's editorial staff” when in fact the crucial aches and pains questions was selected by Eli Lilly’s marketing team to encourage patients to ask their doctors for Cymbalta.

The company's blatantly deceptive techniques are particularly ironic given that WebMD's CEO, Wayne Gattinela, likes to talk up "transparency" in interviews about his company. Clearly, WebMD would never allow transparency to get in the way of an Eli Lilly payday.

And let's not forget WebMD's subsidiary company Medscape. They have a record of lousy ethics and of biased, misleading, and commercially compromised content. Here are two examples:http://hcrenewal.blogspot.com/2008/06/medscapes-cme-ethics.html

Dr. Hassman,I guess I'm lost. Why would Lilly not sample 20mg pills, if 20mg worked as well? Wouldn't they sample pills with as little active ingredient as possible, in order to reduce the cost per pill? Or is it that their own research shows that pt's are more likely to be successful with 60-120mg per day, so that is what they sample - in order to help assure pts are successful, and therefore keep taking (i.e. buying) Cymbalta? If they thought it would increase their profits, they would sample 20mg pills. In this case, the profit motive sort of matches clinical data. For pt's who are extremely susceptible to SE's, or when cross-tapering, you can Rx the lower dose pills. But for others, it is likely a waste of the pts' time and prolongs their suffering.

Though, honestly, I rarely see a need to start Cymbalta when cheaper, equally effective alternatives are available - and unremitted symptoms are likely to respond to therapy. I recommend therapy for all non-psychotic patients leaving our psych ER (and some psychotic ones), but few pursue it.

The Cymbalta experience is uniquely perverse from both medical and business perspectives. The higher doses may not have more therapeutic value, but guess what? The side effects continue to ramp up with the dose!

And you are correct, Cymbalta does comes in a little used 20 mg formulation. But guess what again? When you need to taper off the stuff, even 20 mg is too much! So you have break apart the capsules and count beads! For weeks! All the while the discontinuation is turning both your body and your brain inside out.

I made a presentation to the FDA Psychopharmacological Drugs Advisory Committee last June about the absolute mess that Cymbalta withdrawal can be and the fact that Eli-Lilly evades any responsibility in educating consumers and physicians. My presentation can be found at the FDA site here:

Peruse those over a cup of coffee and then ask yourself if you’d ever want your kids on that stuff. (Because Lilly is currently conducting a pediatric clinical trial and discontinuation is not one of the study factors. So the kiddies are next...)

My presentation was rational and factually made, but of course the issue disappeared into the black hole that is the FDA bureaucracy.

Incidentally, I made reference to a Fibromyalgia CME presentation by Dr. Daniel Goldenberg who pimps for Eli-Lilly. It can be found here:

http://www.cmellc.com/onlinesymposia/w08481/Slides_08USPC_13-0.pdf

Starting on page 20, Dr. Goldenberg segues to a head to head comparison of Cymbalta versus Lyrica. And he does a very slick reptilian sleight of hand. Rather than pump Cymbalta, he does a total smack down on Lyrica. So guess how it implicitly closes? Cymbalta is the only SNRI left standing! And from Goldenberg’s calculated omissions, it’s totally benign! How clever…

Incidentally that intellectually tainted CME course had been prominently displayed on the Psychiatric Times web site which Dr. Pies runs. That’s where I found it.

So there you have it. In a lot of respects the drug stinks, how it is marketed stinks and the providers in bed with Lilly stink.

SteveM,Thank you for the links. I will probably use the presentation to the FDA as a teaching example of how manufacturers skirt around the truth and pretend to be out in front of an issue when, in fact, they've just glossed over it so that you know nothing. But I'll only use it if it is okay with you. Please email me particulars so that I can give you credit. gewisn@yahoo.com

As for those in bed with drug companies, we agree. It is corruption - pure and simple. We all decry when legislators are receiving huge donations, gifts, etc from corporations looking for a vote on the floor and we are disgusted when pentagon officials accept gifts in exchange for buying equipment that isn't right for our troops, etc., etc. Physicians making treatment decisions for patients should not be taking anything from people representing one treatment over another. "I'm too smart to have that affect my prescribing practices," means you are NOT smart enough to understand how it happens and that companies wouldn't spend millions doing it if it didn't work.

Now we learn that we need to have information sources like WebMD declare their financial connections to the industries on which they report.

The current practice of much of medicine and of which psychiatry is likely the worst offender is so hopelessly corrupted as to be almost a lost cause. The US psychiatric paradigm is one that supports the use of medications which have poor if any efficacy over placebo for the TX of wishy washy constructs that have poor reliability and scientific validity. Our entire approach to both the education of primary care Drs and psychiatrists has evolved based upon an unholy alliance between industry and researchers who pimp themselves out in support of this process which has been evolving since the 1950's. Drs are not educated. They are indoctrinated. Now they are beginning to wake up a little and ask what has been going on while at the same time outside entities are beginning to shine a little light on this forcing the cockroaches to scatter.Psychiatry has backed itself into a corner with 15min med checks tossing out pills that have very little support for most who get them and that may be a bitch to get off of. However, if they all stop doing this they will be out of not only jobs but a world view as well. What's a poor psychiatrist to do these days? Maybe take some Cymbalta.

Dr John's concerns are correct about pervasive corruption, but exaggerated when suggesting they are worse in psychiatry. Psychiatry is not an overtly worse offender.

Let's look at statins as one example. Probably half the posters on this blog are on a statin. Why? Because they reduce CV events? What percent of the studies have shown that as a Primary Prevention? How many negative studies were buried? How many of the studies show a clinically relevant outcome, as opposed to simply showing a p-value b/c they ran enough participants to ensure they got a result of some sort? Some studies show they reduce "all cause mortality." Does this pass the sniff test? Statins reduce the death rate from car crashes and suicides and murder? What disease is "hyperlipidemia?" It has no symptoms. It has no disability. Treating it is ONLY about reducing risk of other conditions. By the same token, HTN isn't a "disease" at all. Just like hyperlipidemia, it's a simple measurement linked to risk of other conditions and events. And when was the last time a PCP actually pushed a pt to show that lifestyle changes didn't work before Rx'ing. My PCP wouldn't discuss the other med. classes until I argued for 15 min that my lipid profile responds better to non-statin meds. My next PCP made be bring in reprints, rather than looking it up himself (but then he thanked me for setting him straight).

How many PCP's follow the recommended algorithms for HTN control, but instead add-on a more expensive med before maximizing the first, or jump straight to a more expensive (read "heavily marketed") class? Nurses and doctors arrive to work sniffling, saying, "he said it's viral but he prescribed an antibiotic 'just in case.'" When I do get what looks like a bacterial resp. infection, I have to argue to give me a cheap macrolide because "nobody can tolerate those" even though I just finished explaining that I've always tolerated them.

Please don't take any of this as a condemnation of PCP's. It isn't. They work VERY hard trying to manage the healthcare of all the little things and the big, chronic things, and everything in between. Constantly squeezed by every possible competing agenda. And all without the "luxury" of the 1-hr evaluation of a new pt with multiple health concerns, or even 15 min for a medication check.

As for "indoctrination," it's gratifying to think you are smarter than everyone else. But that may be all it is. As one of the thousands trained in the last 20 years, I can tell you that everyone I know had these questions raised in training. And my med school and residency had active "No Free Lunch" chapters, which are now largely irrelevant b/c both places now prevent the kinds of interactions with drug reps that we questioned. These problems do still exist, but to declare the war a "lost cause" is either an excuse to give up or a simple self-aggrandizement.

And you can see some self-aggrandizement in my own post. I fear the Carlat Blog has become a clubhouse for those who want to gain notoriety for public self (or peer) flagellation.

Regarding Dr John's end comments at his above posting, he is both right and wrong.

Right that psychiatrists have put themselves in a corner forced to just sell meds as their only intervention for patients. Wrong that psychiatrists will be out of a job if they do differently. That is what the other disciplines that, by in large, hijacked mental health care want us and the public to think!

Yeah, colleagues, keep on validating by lack of action or basic plain fear that PCPs are adequate assessors of mental health needs and thus continuing the prescription first and only mentality, that alleged providers without sufficient training can be therapists and accept disgusting low reimbursement rates for basically being guidance counselors, and our alleged KOLs, who are just whores and cowards keep dictating what the direction of psychiatry should be while they are insulated or clueless to the needs of the public.

That is a harsh statement to make. It needs said, and it needs read by others. Because I am not going to have my career ruined because people by in large do not give a damn and just do what it easy, convenient, and politically correct, not as a Washington sense, but a societal correctness.

Thank you for writing what you did, DrJohn. It honestly made my day, because it is now out there, and responded to by at least me.

And, where is the logic that a low dose of a drug should NOT be sampled? More often those I cautiously offered Cymbalta and titrated in increments of 20mg to 60mg daily seem to tolerate it, and that was IF their insurance allowed the prescription to be filled! Another rationing of health care actively in process: "we're not saying the patient can't have the meds you see clinically fit to prescribe, we're just not going to pay for it."

gewisn, I would agree completely with your comments on statins and as a psychiatrist it is just easier for me to point out the flaws in my own field but I do recognize that these problems are pervasive in all of organized medicine. When I use the word "indoctrination" it is not to point out my mental superiority. I was in fact indoctrinated as a resident not really taught. What I was not taught in either medical school or training was to detect bullshit. If detecting bullshit makes me smarter than everyone else than I have become a friggin genius because I look for bullshit and see it in almost every claim and crap research study published.I have been part of the problem too. I used to be a 2k a talk pharma speaker until I woke up. I lived the lie. I am not so smart but I have gotten honest. Effect sizes are grossly distorted to present marginal therapies as being helpful and worth the risks while minimizing the risks and painting their use as a standard of TX. Antidepressants are a perfect example of drugs that may have marginal benefits for a few but have been sold to the masses just like statins have. Now after 20 years of being told they were the bees knees we are told they suck but antipsychotics for your depression are fantastic. Well I knew they sucked already. I have read the hx of medicine and it is littered with horror stories but one thing I seem to read is that Drs used to have a sense of skepticism and greater objectivity. Our current approach to generating junk science and passing the results on to Drs appears to have horribly eroded that intellectual independence. Perhaps I over state my case and I am prone to hyperbole but frankly we are all better off as are our pts if we are a little more prone to overstating our objections to what has happened to our field rather than understating them. Dr Hasserman is right in that if psychiatry will ever emerge with any integrity it better step away from the disastrous path it has been on for the past 20 years.

WebMD/Medscape is a nothing more than a mouthpiece for Pharma. What *isn't* though? They own the world. Look at sites like depression.com, bipolar.com. They advertise the disease to sell their drugs. I'm just waiting for an act of God. It's too late for half-measures. http://tiny.cc/debcz

I disagree that psychiatrists will be out a job if we stop doing 15 min med checks. I do 45 min sessions for most of my patients, and 30 min sessions for the rest. I do no advertising and am not even in the phone book because I already have more people call for help than I can handle.

True, I make a lot less than if I did "med checks". And, I also have a lot of job satisfaction, and by observing the interactions between medications, medical illnesses, and mental health with therapeutic techniques I have learned far more than by just prescribing. So my work is very intellectually satisfying. I also know other psychiatrists who use this approach (though the percentage seems low).

I don't know if my model would work for everyone as solo practice or small group practice may require special conditions which are not present everywhere.

In my office I've been having an ongoing discussion with the sales rep for a certain atypical antipsychotic (we'll call Drug "A") about its use in schizophrenia, bipolar disorder, and depression. Whenever I share a patient's symptoms with her, she finds it necessary to immediately determine the proper diagnosis and the correct starting dose (2, 5, 10, 20 mg, etc) based, presumably, on what she' been told at her sales meetings.

It's almost laughable, since it's obvious she was not sitting in the room listening to the patient, she has no idea what the patient's other medications or medical concerns are, his/her other therapeutic options or the history of the patient's disease. She ignores these "peripheral" issues and instead hammers forth the dosing strategy instilled in her by the sales team.

The sad part, though, is that I know doctors whose sole source of information is these sales reps, who will take her suggestions and, as soon as they see what they think (i.e., what they've been trained to believe) is the right diagnosis, they'll jump right to her med at the dose she has recommended.

When my colleagues and I get more information from the sales reps than from journals or textbooks (or patients!), it's a sad day for psychiatry.

As a "victim/survivor" and advocate, I have to say some of the comments here shock even me with their bitterness. Wow -- I'm glad so many of you have greater awareness of the fraud that's being perpetrated on medical professionals in the name of science. I agree that Cymbalta is an evil drug -- after all it killed a young woman (Traci Johnson) in clinical trials and still got approved.

As for dosages, big pharma has no interest in pushing small doses -- don't they cost less? Set me straight if that's not the case, but furthermore patients get hooked on the bigger doses more easily and have a harder time getting off and that's in the interest of big pharma in case you hadn't noticed. The small doses are much safer (if any doses are safe) and less likely to cause akathisia and all those other nasty side effects. I personally know someone who did well on 5mg of Paxil. At some later date she went up to 20 and became suicidal. Just saying. . . Keep the outrage coming. It warms my heart.

re: Cymbalta and the nightmare that ensues when a patient attempts to taper from it. The tiny beads in the cap make it impossible to titrate properly, almost giving thought to the idea that LILLY purposely created the drug that way.

Cymbalta, tested for incontinence, used and promoted for knee pain, fibro, and depression appears to be Lilly's "all-purpose" drug that includes a suicidality risk and a withdrawal challenge....my question to the professionals here discussing dosing and rx'ing of the drug:

Do you warn your patients that the drug might be difficult to remove, that if they decide to increase or decrease the dose they can suffer? (withdrawals can include diarhea, headache, brain zaps, etc).

That is another part of appropriate informed consent.

As far as Internet reading for information, NAMI is also in bed with pharma, and investigated by Grassley, just like some of the KOL's and the APA.

I find patient anecdotal stories cross-checked on many site and forums to be a good tool, and for professionals, it might not hurt to take a look and read them, the people ARE patients, and many suffer withdrawals, which is rarely discussed by doctors (acknowledged).

Refreshing to read any doctor comment that they understand withdrawals from psych meds, because these drugs are in fact difficult to remove without bodily functions affected.

I for one have never started any pt on Cymbalta and see no reason too. I am very slow to use any new drug as old ones are cheap and just as good(but not very good) and I take no pharma money or food nor have seen or spoken to a rep in 5 years. By the time it had been on the market long enough for me to use it I had already heard enough reasons not to.

And for what it's worth, it's my theory that the reason drugs like Cymbalta "work" for fibromyalgia and related pain is because drugs like Cymbalta, i.e. other psych drugs, actually cause the problem in the first place in many, if not all, cases and, either because of withdrawal or "poop out," the "cure" comes from adding back a similar agent. It's a temporary fix at best and only postpones the day of reckoning. The only real cure is to get off all those immuno-compromising agents and hope your body can recover on its own. Radical I suppose, but that's what I believe. If you have mysterious and unexplained pain and fatigue, it's a darned good idea to look at treatment history and see just what precipitating agents there might be there lurking in your medical records. Psych drugs have all sorts of side effects that are overlooked and mistaken for weird ailments that we claim not to understand. What a racket for the drug companies!

I agree with the post that asked, "What websites should we recommend to patients/clients? I work with families whose family members are new to mental health systems and medications. I want to be able to provide them with good information that is not just from drug companies. Would everyone recommend Mayo's sites?Gail Olson, PhD, Omaha, NE

I was very surprised to find this in a book about loss and grief that was published in 1976: "Severe, chronic depression is a prevalent and well-recognized medical disorder, one as treatable as diabetes or hypertension....Severe biological depression resutls from a biochemical imbalance in the brain. Antidepressants are non-addictive and effective." Wow, we were certainly sure of ourselves, weren't we? Here we are 34 years later and still haven't proved the biochemical imbalance plus we know that antidepressants (at least the SSRIs, which I don't think were out in 1976)can have significant side effects not to mention challenging withdrawal symptoms. And this book was before direct marketing to consumers. The "brainwashing" (sorry for the pun) started early.

The warning letter details the voodoo statistics Lilly used in the promotion. The clinical study total dropout rate was huge (35%). And the subjects who dropped out because of side effects were counted as successes.

If you noodle through the stats and the complete side effect profile highlighted in the warning letter, it becomes clear what a craptastic drug Cymbalta really is.

Of course you docs rarely become aware of the basis for the warning letters. Unless the drug reps have an epiphany of good conscience, barge into your offices and blurt out the Cymbalta downside with irrational honesty.

At the end of the day though, Lilly just tweaks the ad copy and it's business as usual. They still got the deceptive message out for months and months and it cost them nothing.

Just a little testimony.I'm a former shrink (clinical psychologist) who has abandoned my practice. My husband is a shrink (psychiatrist). We live in France.My husband has 45 minute sessions with most of his patients (he can go under AND over sometimes...)He does NOT prescribe. Nada. Nothing.People come to him to TALK.He's working just fine, and we're living well (but frugally) on what he makes.He sees NO pharma representatives.I dropped my practice after a major spiritual crisis. (Yeah, some people might say "depression"... What's in a word ? Everything. Freud found THAT out.)My GP held me up, and pulled me through. With a little help from antidepressants. But it was mostly him, and the fact that he talked me through ALL the side effects that I could expect from the meds. AND he gave me his cell phone number, telling me that I could call him any time of the day or night if I had to. I didn't...)The shrink that I was seeing at the time kept his lips pursed the whole time I was falling apart in his office.Thanks to my husband, who physically pulled me out of bed some days (and didn't farm me out to the local mental health hospital...)The other day on Salon which has a really inflammatory, cheesy approach to the questions you are dealing with on this blog, I read an article by a young woman who was all excited to discover that she "had" PTSD following a delivery where she was treated like a piece of meat by the white lab coats in the operating room.Sigh. What can you say about that kind of thinking ?That it is alienation ? Right. I say that it is alienation.. Let's do our best NOT to encourage it.By..LISTENING to our patients. (By the way, opening up advertisement for meds is a REAL Pandora's box...)

Freud's nephew Edward Barnays began to use sophisticated techniques to get women to smoke. Bernays's techniques have been applied to media like websites and television adds to make healthy people feel they need to compromise their lives by taking a pill to be "happy", "thin", "awake".

The worst part is women are targeted for this because they are more susceptible to advertising that makes them dissatisfied with their lives.

I can't believe the Pristiq commercial. http://sadnessaddiction.blogspot.com/ It makes me think that the FDA has hired from Fannie Mae and Freddie Mac and are selling antidepressants like high risk mortgages. When does the bubble burst? I am beyond disgusted

A. How would you know that, since you likely aren't doing followup on ER pts.?B. Let's see... miss work to go for pathetic and, frankly, pointless 15 minute med checks at the psychiatrist's office, or miss work for 15 minute med checks AND for 50 minute therapy sessions every week. Hmm... it seems to me like patients might be able to miss work less often and have more access to therapy if PSYCHIATRISTS were doing it during med checks. But since it's not about the patient, but instead about the psychiatrist's wallet, that will never happen. So patients will continue to choose going to work instead of following your recommendation that they seek therapy... since they NEED TO EAT. The assembly line treadmill will continue into the foreseeable future thanks to the biomedical model that excludes the person and instead turns them into a sack of symptoms.

A. How would you know that, since you likely aren't doing followup on ER pts.?B. Let's see... miss work to go for pathetic and, frankly, pointless 15 minute med checks at the psychiatrist's office, or miss work for 15 minute med checks AND for 50 minute therapy sessions every week. Hmm.... So patients will continue to choose going to work instead of following your recommendation that they seek therapy... since they NEED TO EAT."

A. I know because most end up coming back to the ER because the situation at home has not improved and because I sometimes can see the outpt records when they do return and because I also work in the outpt clinic.

B. I DO incorporate, into every outpt appt and every ER visit, talk about ways to improve the internal environment (like exercise and volunteering and attending religious services) and the external environment (how to get along w/ people, interpersonal negotiations, etc). 90% are not working because their symptoms are too severe. But most still do not go to therapy. Many tell me they stopped therapy a long time ago because they got tired of talking endlessly about the same childhood issues and months/years spent getting "to the root of the problem."

I'm seeing more results (and more attendance) now from groups provided at our county clinics focusing on problem-solving for current daily problems, incl substance use.

sadnessaddicted -"The worst part is women are targeted for this because they are more susceptible to advertising that makes them dissatisfied with their lives."

Citation, please. Exactly which research determined that women are more susceptible to advertising that makes them dissatisfied with their lives? I would really like to know. Until I do, I will assume that women are shown in psychopharm ads more often than men because women are disproportionately represented when it comes to the universe of psychiatric patients.